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Vascularised fibular grafts (VFGs ) are a valuable surgical technique in limb salvage after resection of a tumour. The primary objective of this multicentre study was to assess the risk factors for failure and complications for using a VFG after resection of a tumour.The study involved 74 consecutive patients (45 men and 29 women with mean age of 23 years (1 to 64) from four tertiary centres for orthopaedic oncology who underwent reconstruction using a VFG after resection of a tumour between 1996 and 2011. There were 52 primary and 22 secondary reconstructions. The mean follow-up was 77 months (10 to 195).In all, 69 patients (93%) had successful limb salvage; all of these united and 65 (88%) showed hypertrophy of the graft. The mean time to union differed between those involving the upper (28 weeks; 12 to 96) and lower limbs (44 weeks; 12 to 250). Fracture occurred in 11 (15%), and nonunion in 14 (19%) patients.In 35 patients (47%) at least one complication arose, with a greater proportion in lower limb reconstructions, non-bridging osteosynthesis, and in children. These complications resulted in revision surgery in 26 patients (35%).VFG is a successful and durable technique for reconstruction of a defect in bone after resection of a tumour, but is accompanied by a significant risk of complications, that often require revision surgery. Union was not markedly influenced by the need for chemo- or radiotherapy, but should not be expected during chemotherapy. Therefore, restricted weight-bearing within this period is advocated.Cite this article: Bone Joint J 2015;97-B:853–61.

Der Komplettverlust der Achillessehne gilt als stark beeintrachtigende Verletzungsfolge, daher wird eine Rekonstruktion angestrebt. Diese Studie stellt erstmals eine standardisierte Nachuntersuchung von Patienten mit Verzicht auf eine sekundare Rekonstruktion nach infektbedingtem Totalverlust dar. Sieben Patienten mit Achillessehnendefekt nach auswartigen Rekonstruktionsversuchen erhielten eine Weichteildeckung ohne Sehnenrekonstruktion. Durchschnittlich 11 Monate postoperativ erfolgte eine Evaluation der Sprunggelenksfunktion u.a. durch den AOFAS-Score und isokinetische Kraftmessungen mit dem Biodex®-System. Alle Patienten zeigten hohe Mobilitat und Kraftentfaltung der unteren Extremitat. Der AOFAS-Score betrug 84,7 (max. 100), die Kraftabnahme fur Plantarflexion 44,5% verglichen zur Gegenseite und entsprach damit Ergebnissen nach sekundaren Sehnenrekonstruktionen. Nach Totalverlust der Achillessehne bestehen kompensatorische Mechanismen, die, verglichen mit Ergebnissen nach sekundaren Sehnenrekonstruktionen, einen groseren Kraftverlust verhindern und neben regularen Alltagstatigkeiten sogar Spitzensport erlauben.

Antimikrobielle Peptide sind naturlich vorkommende kationische Peptidmolekule. Die erste Verteidigungslinie der Verbrennungswunde stellt das angeborene Immunsystem dar, deren Bestandteile diese Peptide sind. Um die topische Anwendbarkeit in infizierten Verbrennungswunden zu vereinfachen wurde die Wirksamkeit in Fibrinkleber in vivo und in vitro getestet. Nach In-vitro-Testung erhielten 15 mannliche Sprague-Dawley-Ratten eine tief zweitgradige Verbrennung, wurden mit multiresistenten Pseudomonas aeruginosa infiziert und mit Protegrin-1 (PG-1; 100 μg/ml, n=5), Fibrinkleber (n=5) oder einem Gemisch aus beiden (n=5) topisch behandelt, die Wirkung wurde zuvor durch einen Radial-Diffsusions-Assay bestatigt; 24 h spater wurde die verbrannte und infizierte Haut gewonnen und die Bakterienanzahl pro Gramm Haut bestimmt. In vitro lies sich die biologische Aktivitat bestatigen. Die Gruppe aus entweder PG-1 oder Fibrinkleber zeigte in vivo keine signifikanten Unterschiede in der Bakterienanzahl, hingegen lies sich in der Gruppe des Gemisches eine signifikante antibakterielle Wirkung nachweisen (p

On January 1st 2004, a new contract between the government, health insurance services, and hospitals was inaugurated in Germany. The aim of the contract is to decrease costs for surgical therapies by abolishing or at least minimizing hospitalization of patients. Hand surgery is widely affected by the new contract, since a very large part of surgical therapies for the hand was declared to be compulsory outdoor and another major part to be preferable outdoor. The surgeon may decide whether a patient needs inpatient or outpatient treatment but has to justify his decision. Hospitals and surgical clinics are both allowed to offer outpatient hand surgery and get the same payment under the same regulations. For most hospitals, structural changes will be necessary to offer outpatient surgery without financial loss. In our experience a personal and regular contact between patient and surgeon is most necessary for the best surgical result. Many of the compulsory outpatient operations in hand surgery can be done sufficiently and at high standard. This may not be the case for the second group to be handled not compulsory outdoor. The new contract allows hospitals to offer postoperative care for only 14 days, whereas many specific hand surgical procedures will need the surgeon's control and care for a much longer time. On the other hand, clinics and general practitioners have strict limitations for the prescription of hand therapies. We believe that the quality of hand surgery is highly dependent on sufficient postoperative treatment. If the postoperative care is neglected or restricted, secondary costs such as sick leave will increase.

Wir untersuchten 53 Patienten mit 57 Radiuskopfchenfrakturen (4 Patienten mit einer beidseitigen Fraktur) aus den Jahren 1993–1998 nach und befassten uns mit den Radiuskopfchenfrakturen unter folgenden Fragestellungen: 1. Zusammenhang zwischen dem Fraktur-Typ und der jeweiligen Therapie? 2. Zusammenhang zwischen dem gewahlten Behandlungsverfahren und dem Ergebnis? Folgende Frakturen traten auf: Mason I: 3 Falle, Mason II: 26 Falle, Mason III: 11 Falle, Mason IV: 15 Falle. 30 Patienten mit 31 Frakturen hatten postoperativ ein gutes, 8 Patienten mit 9 Frakturen ein zufriedenstellendes und 13 Patienten mit 14 Frakturen ein schlechtes Ergebnis. Die Patienten mit einer Mason-I-Fraktur hatten unter funktioneller Therapie ein gutes Ergebnis. Von den 26 Mason-II-Frakturen wurden 14 Patienten mit Hilfe einer Kleinfragmentschraube oder Ethipins behandelt, von denen subjektiv 14% ein dauerhaft schlechtes Ergebnis hatten. 6 Patienten wurden mittels K-Draht, Titan- oder Prevot-Nagel behandelt, keiner dieser Patienten hatte ein schlechtes Ergebnis. 10 Patienten mit einer Mason-III-Frakturen wurden bei uns mit einer Resektion des Radiuskopfchens behandelt. Bei dem 11. Patient haben wir aufgrund einer intraoperativ festgestellten Ellbogengelenkinstabilitat nach erfolgter Resektion eine Prothese mit einem guten postoperativen Ergebnis implantiert. Letztendlich bestand bei nur einem Patienten (9%) ein subjektiv schlechtes Ergebnis. Patienten mit einer Mason-IV-Fraktur wurden in 11 von 15 Fallen mit einer Resektion des Radiuskopfchens behandelt. Hierunter zeigte sich bei 5 Patienten (33%) ein objektiv schlechtes Ergebnis, wobei nur 3 Patienten (20%) dies subjektiv so empfanden.

Power lifting injuries most often involve shoulder injuries with an injury rate of 0.57 to 0.71/1000 hours of power lifting. Wrist injuries are less common in power lifters with 0.05/1000 hours exposure vs. 0.23/1000 h in elite weight lifting men. Often, two contributing factors causing wrist injuries are encountered: a) loss of balance causing the barbell to drift back behind the head of the power lifter, which hyperextends the wrist and b) the maximal weight. We report on an elite power lifting athlete preparing for the World Masters Bench press championships suffering two months of persisting pain during bench press exercise and rest in the snuff-box area following a loss of balance of the bar-bell during bench press with 280 kg load. Following prolonged presentation 2 months after the initial injury with training in the meantime, CT-scan was performed revealing a C-type scaphoid fracture. Surgery was performed as Herbert screw fixation and bone grafting according to the technique of Matti-Russe, followed by an immobilisation of twelve weeks with a plaster. We recommended ending the athletes' power lifting career, however he further exercised with the plaster with consecutive re-operation 3months later and 2nd Matti-Russe and Herbert screw re-do. One year later he became national champion with 240 kg bench pressing. Given the limited scaphoid blood supply and the high complication rate especially among C-type scaphoid fractures, a surgical procedure with bone grafting, Herbert screw fixation and sufficient plaster immobilisation is advocated in scaphoid fractures in elite athletes.

The scapulothoracic dissociation (SD) is a complex injury of the shoulder girdle, mostly associated with polytraumatized critically ill patients. This case report of 3 patients shows the variety of possible injuries combined with SD. Diagnosis and therapy in such a rare trauma, which is most likely seen in specialized trauma centres are being described. The 3 patients are presented from trauma to management, with remarks to various possibilities in treatment. Reports of other groups include multicenter studies with small numbers of patients, making it different to look for homogenity or defining standards, whereas current guidelines are being mentioned, including remarks on the management of these mostly polytraumatized and vitally endangered patients.

3D technology is increasingly being applied in dentistry and in oral and maxillofacial surgery. An important field of application is reconstructive surgery, especially in the reconstruction of large defects ofthe jaw. In such cases of reconstruction, the goal is the restoration of both the continuity of the defective area and its function. For the functional restoration implant supported dental structures are often employed. In such cases, CAD/CAM superstructures, 3D printed drill and saw templates, anatomical models, wafers and surgical outcome models are used. The combination of the digital planning and the digital fabrication ofsuperstructures and surgical aids offers many preoperative advantages. The use of saw, drill and positioning templates provides for accurate segmentation and implant positioning, by means of which the reconstruction can be carried out in a predictable way.

Open fractures are complex injuries affecting the integrity of bones and adjacent soft tissue. The therapeutic goals in dealing with open fractures should consist of primary osteosynthesis in conjunction with functional reconstruction of soft tissue. In a period over 2 years, 26 patients were treated with extensive trauma in an interdisciplinary approach. These patients suffered from open fractures type 2 and 3. All patients were treated by primary osteosynthesis, and temporary wound closure with V.A.C.-system. Definitive wound closure was achieved by day 31 after injury. In contrast to a review of the pertinent literature we report the successful free tissue transfer in 21 patients during the critical period between 72 hours and several months preceded by the use of V.A.C.-system for the temporary coverage of open wounds.

Grundlagen: Akute oder chronische Weichteildefekte nach operativer Therapie von Schienbeinkopfbruchen stellen eine schwerwiegende Komplikation dar. Um eine chronische Infektion des Knochens zu verhindern oder bei manifester Osteomyelitis die Infektbeherrschung zu ermoglichen, ist eine suffiziente Weichteildeckung eine conditio sine qua non.

Power lifting injuries most often involve shoulder injuries with an injury rate of 0.57 to 0.71/1000 hours of power lifting. Wrist injuries are less common in power lifters with 0.05/1000 hours exposure vs. 0.23/1000 h in elite weight lifting men. Often, two contributing factors causing wrist injuries are encountered: a) loss of balance causing the barbell to drift back behind the head of the power lifter, which hyperextends the wrist and b) the maximal weight. We report on an elite power lifting athlete preparing for the World Masters Bench press championships suffering two months of persisting pain during bench press exercise and rest in the snuff-box area following a loss of balance of the bar-bell during bench press with 280 kg load. Following prolonged presentation 2 months after the initial injury with training in the meantime, CT-scan was performed revealing a C-type scaphoid fracture. Surgery was performed as Herbert screw fixation and bone grafting according to the technique of Matti-Russe, followed by an immobilisation of twelve weeks with a plaster. We recommended ending the athletes' power lifting career, however he further exercised with the plaster with consecutive re-operation 3months later and 2nd Matti-Russe and Herbert screw re-do. One year later he became national champion with 240 kg bench pressing. Given the limited scaphoid blood supply and the high complication rate especially among C-type scaphoid fractures, a surgical procedure with bone grafting, Herbert screw fixation and sufficient plaster immobilisation is advocated in scaphoid fractures in elite athletes.

Structural full-thickness defects of the Achilles tendon represent a severely disabling injury which should be treated by reconstruction. This study presents functional outcomes from standardised follow-up of non-reconstructed Achilles tendons with soft tissue coverage alone.Seven patients were treated with various techniques of soft tissue reconstruction without restoration of the Achilles tendon. After a mean of 11 months postoperatively, the lower extremity was evaluated generally with regard to function, AOFAS score (ankle and hindfoot), and isokinetic torque testing by the Biodex system.All patients showed high mobility, muscle strength, and range of motion at follow-up. The average AOFAS score was 84.7 (maximum 100), and the torque loss in plantar flexion was 44.5% on average compared to the uninvolved side and thus comparable with results after secondary tendon reconstruction.After complete loss of the Achilles tendon, compensatory techniques can hinder significant loss of torque and endurance, compared with secondary tendon reconstruction, allowing unsupported mobility and even top athletic performance.

Extensive locoregional recurrency or metastatic involvement of brachial plexopathy is a condition that is often associated with advanced systemic breast cancer. In the past the role of surgeon was restricted due to a scepticism as to whether any benefit will be provided for the patient. In the recent 25 years however safe and refined plastic surgical approaches have been developed that provide more options to treat even complex recurrent disease. The strategy of plastic surgery in an interdisciplinary approach of gynecology, oncology and radiotherapy as well as thoracic surgery is outlined.

Antimicrobial peptides are naturally occurring cationic peptides. The first-line of defense in infected burns is the innate immune system, of which antimicrobial peptides are essential parts. To facilitate their topical use in infected partial-thickness burns, the efficacy of a mixture with fibrin glue in vitro and in vivo was tested.After in vitro tests, 15 male Sprague-Dawley rats received partial-thickness burns. Afterwards, the wounds were infected with multiresistant Pseudomonas aeruginosa. The animals received PG-1 (100 microg/ml, n=5), fibrin glue (n=5), or a mixture of both (n=5) topically. The efficacy of the materials was previously proven by radial diffusion assay. After 24 h, the infected and burned skin was harvested and quantitative bacterial counts per gram of skin performed.The biologic effect of the peptides was confirmed in vitro. The PG-1 and fibrin glue groups did not show significant differences in bacterial numbers, whereas the mixture group showed significant reduction in Pseudomonas in vivo (P0.04 and P0.01).A mixture of an antimicrobial peptide and commercially available fibrin glue is capable of significantly reducing bacteria in infected partial thickness burns in vivo compared to controls.

The success of a free flap transplantation is based on a sufficient microanastomosis which meets the following requirements: a pedicle placed without kinking or twisting, a good drainage, a well defined recipient vessel and integrity of the endothelium. The aim of this study was to determine whether operation-related ischaemia through flap transplantation and tourniquet induces an increase of Endothelin-1 plasma levels as one cause of vasospasm during microvascular procedures. We focused our attention in particular on the reperfusion period which is often limited to an irreversible perfusion failure of microcirculation due to free radicals, interleukin and Endothelin-1. Twenty-one patients with tissue injury of the lower leg were included in our study, fourteen underwent a latissimus dorsi muscle transplantation with a combined ischaemia, seven patients had a tourniquet ischaemia for tumour resection, debridement and local flap transfer. The duration of ischaemia varied due to the course of operation. The withdrawal of venous blood via central vein catheter, flap vein and wound bed followed a fixed time table pre- and post-reperfusion (T1: preoperative day via cubital vein, T2: 6th postoperative day, T3: 5 min, T4: 10 min, T5: 15 min, T6: 1 h post-declamping and after tourniquet ischaemia via central vein catheter and T7: within 5 min from the flap vein immediate after recharging the flap). The vessel anastomosis determined the withdrawal from the local wound bed. ET-1 in venous blood samples were measured with ELISA. The duration of ischaemia in the tourniquet group ranged from 22 min up to 210 min with a mean of 76.58 min and in the latissimus group from 87 min up to 203 min with a mean of 139.21 min. The mean ET-1 plasma concentration measured systemically before operation in the 21 patients was 0.51 +/- 0.08 pg/ml (Mean +/- SD). This result corresponds with data published in literature. The locally measured plasma levels of ET-1 after tourniquet and flap ischaemia were increased with 0.34 up to 3.90 pg/ml (0.95 +/- 0.79 pg/ml [Mean +/- SD]) for the tourniquet group and with 0.34 up to 14.87 pg/ml (1.85 +/- 3.64 pg/ml [Mean +/- SD]) for the latissimus group. This is an increase compared to systemically measured values as 0.75 +/- 0.06 pg/ml (Mean +/- SD) for the tourniquet group and 0.58 +/- 0.21 pg/ml (Mean +/- SD) for the latissimus group. We conclude that Endothelin-1 is increased locally in the early reperfusion period after free latissimus dorsi-transplantation.

Tissue engineering research has demonstrated the potential of a variety of different matrix materials to enable cell adhesion, diffusion of nutrients, vascular ingrowth, nutrition and growth promotion. Therefore it appears attractive to apply these features also to topical negative pressure therapy. The article discusses several aspects of foam materials and their possible interactions with the wound surface.

On January 1st 2004, a new contract between the government, health insurance services, and hospitals was inaugurated in Germany. The aim of the contract is to decrease costs for surgical therapies by abolishing or at least minimizing hospitalization of patients. Hand surgery is widely affected by the new contract, since a very large part of surgical therapies for the hand was declared to be compulsory outdoor and another major part to be preferable outdoor. The surgeon may decide whether a patient needs inpatient or outpatient treatment but has to justify his decision. Hospitals and surgical clinics are both allowed to offer outpatient hand surgery and get the same payment under the same regulations. For most hospitals, structural changes will be necessary to offer outpatient surgery without financial loss. In our experience a personal and regular contact between patient and surgeon is most necessary for the best surgical result. Many of the compulsory outpatient operations in hand surgery can be done sufficiently and at high standard. This may not be the case for the second group to be handled not compulsory outdoor. The new contract allows hospitals to offer postoperative care for only 14 days, whereas many specific hand surgical procedures will need the surgeon's control and care for a much longer time. On the other hand, clinics and general practitioners have strict limitations for the prescription of hand therapies. We believe that the quality of hand surgery is highly dependent on sufficient postoperative treatment. If the postoperative care is neglected or restricted, secondary costs such as sick leave will increase.

Introduction: LPS-Binding-Protein (LBP), a class I acute phase protein, is capable of enhancing inflammatory cytokine production in response to LPS (lipopolysaccharide, endotoxin). It also functions as an opsonin for Gram-negative bacteria and reduces by 10,000-fold the concentration of neutrophil derived BPI (bactericidal permeability increasing protein) necessary to kill Gram-negative bacteria. Wound infection after thermal injury is a major source of morbidity and mortality. By increasing LBP at the site of burn injury we anticipate increased wound bactericidal activity by potentiating neutrophil and macrophage recruitment, activation and bactericidal killing, therefore we hypothesize that increasing levels of LBP by means of local gene therapy leads to decreased bacterial infection in burn injury. Materials and Methods: 13 female inbred LBP-knockout (LBPko) mice and 13 age- and weight-matched pathogen-free C57b wild-type (C57BL6) mice received a 25% body surface partial thickness (IIb) burn wound. Postb the burn area received intradermal injection of 1010 pfu of designed adenoviral constructs expressing either rat-LBP or beta-galactosidase (control). After 72 hrs 105 Silvadene®-resistant P. aeruginosa were topically applied and occlusively covered. Another 72 hrs later, animals were sacrificed, the treated skin was harvested for histology and quantitative bacterial cultures. Results: In wild-type animals (C57BL6), treatment with LBP-adenovirus resulted in significantly lower bacterial counts than animals treated with the control adenovirus (p < 0.04). Overall, bacterial counts were reduced 44.3 fold. Histology, Western blotting and X-gal staining revealed efficacy of the experimental design and viral expression. Conclusions: Our findings demonstrate for the first time that local gene therapy-driven over-expression of LPS-binding-protein (LBP) can suppress bacterial infection within burn wounds. These findings confirm LBP’s importance in host immune defense against Gram-negative infection and support a possible feasibility of local gene therapy for the treatment of burn injuries.

Moderne plastisch-chirurgische Rekonstruktionsverfahren haben wesentlich zur Verbesserung der Behandlungsergebnisse bei offenen Frakturen und Gelenkinfektionen beigetragen. So ist der Einsatz Weichteil-plastischer Methoden heute ein integraler Bestandteil des interdisziplinaren Vorgehens in dieser problematischen Patientengruppe [11].

We investigated 53 patients with 57 radial head fractures (4 patients with bilateral fractures) treated between 1993 and 1998. We focused on patients with radial head fractures asking about (1) the relation between fracture type and therapy and (2) the correlation between chosen treatment and result. We saw the following fractures: Mason I: 3 cases, Mason II: 26 cases, Mason III: 11 cases, and Mason IV: 15 cases. Good results were achieved by 30 patients with 31 fractures, fair results by 8 patients with 9 fractures, and poor results by 13 patients with 14 fractures. Patients with a Mason I fracture achieved good results with functional therapy. Of the 26 Mason II fractures, 14 were treated with screws, 14% of whom had poor results subjectively. Six patients were treated with a K wire, titanium nail, or prevot nail, none of whom had poor results. Of 11 patients with a Mason III fracture, 10 were treated by resection of the radial head, and in 1 patient we implanted a prosthesis due to an intraoperatively detected elbow instability after resection and achieved good postoperative results. Only one patient (9%) had poor long-term results subjectively. Of 15 patients with a Mason IV fracture, 11 were treated by resection of the radial head: 5 patients (33%) had poor long-term results, only 3 of whom (20%) subjectively considered the results poor.

Posttraumatic stiffened joints are mostly well restored by means of operation, however, the range of motion remains restricted by secondary soft tissue shrinking and scarring. Conservative treatment yields only limited success rates. Open arthrolysis is a useful tool in regaining function; in postoperative treatment, immediate passive mobilization and prevention of heterotopic ossification are most important.Sixty-nine patients were arthrolyzed on average 25.3 months post trauma, with an average of 1.5 previous operations (range 0-8) and a follow-up period of 14.7 months.By means of the open arthrolysis, an increase in range of motion for flexion and extension of 62.3 degrees (preoperative 38.4 degrees, postoperative 87.9 degrees, at follow-up 100.7 degrees ) and 29.3 degrees for pro- and supination was achieved on average. The highly important range of motion between 0-30 degrees and 110 degrees was accomplished in 78.2 % of the patients. We analyzed the postoperative management including irradiation, pharmacological ossification prophylaxis with indomethacin and immediate passive motion. Whenever the time to arthrolysis exceeded 9 months, clearly worse results were obtained, thus we measured a difference in the correlated increase of motion from 54.3 % - 34.6 %. Comparisons of our results with German (after Blauth and Hipp) and French (after Cauchoix and Deburge) standard follow-up forms are made, and the rehabilitation program is underlined and explained. Another task of this study was to discuss the complication rate.

The scapulothoracic dissociation (SD) is a complex injury of the shoulder girdle, mostly associated with polytraumatized critically ill patients. This case report of 3 patients shows the variety of possible injuries combined with SD. Diagnosis and therapy in such a rare trauma, which is most likely seen in specialized trauma centres are being described. The 3 patients are presented from trauma to management, with remarks to various possibilities in treatment. Reports of other groups include multicenter studies with small numbers of patients, making it different to look for homogenity or defining standards, whereas current guidelines are being mentioned, including remarks on the management of these mostly polytraumatized and vitally endangered patients.

The scapulothoracic dissociation (SD) is a complex injury of the shoulder girdle, mostly associated with polytraumatized critically ill patients. This case report of 3 patients shows the variety of possible injuries combined with SD. Diagnosis and therapy in such a rare trauma, which is most likely seen in specialized trauma centres are being described. The 3 patients are presented from trauma to management, with remarks to various possibilities in treatment. Reports of other groups include multicenter studies with small numbers of patients, making it different to look for homogenity or defining standards, whereas current guidelines are being mentioned, including remarks on the management of these mostly polytraumatized and vitally endangered patients.